THEORETICAL FOUNDATIONS

This CBT program falls theoretically within the framework of social learning theory, in which both behavioral and cognitive information processing approaches to modifying symptoms are emphasized (Foa & Kozak, 1985). In particular, behavioral psychotherapists work with patients to change behaviors and thereby to reduce distressing thoughts and feelings. Cognitive therapists work to first change thoughts and feelings, with improvements in functional behavior following in turn. Our program uses both cognitive and behavioral interventions, and so falls within the purview of CBT. Like pharmacotherapy, which seeks to modify thoughts, feelings, and behaviors by directly manipulating the functional neuroanatomy that mediates these effects, CBT also can be seen as an effective method for returning aberrant central nervous system information processing to a more normal state (Schwartz, 1996).

Externalizing OCD

One key to establishing a successful therapeutic alliance is to clearly separate OCD from the child and family, a process termed “externalizing the problem” by the Australian family therapist, Michael White. Borrowing from White’s narrative therapy techniques (White, 1986; White & Epston, 1990), we describe OCD as an unpleasant and oppressive neurobehavioral illness over which both child and family already have some influence—an influence we and they desire to increase. In this way, therapist, child, and family become members of the same team with a unified goal of helping the child get OCD out of her life.

Gradual versus Intensive Exposure

Anxious youngsters typically like treatment to be predictable and controllable. Graded exposure involves weekly sessions in which the child has explicit control over selection of exposure targets, which are then primarily addressed through homework assignments. This form of gradual exposure provides a greater degree of control than intensive exposure, which relies on daily sessions using therapist-assisted E/RP. Since young persons tolerate anxiety less well than most adults, it helps to make the treatment predictable, controllable, and most importantly, successful. Thus, graded exposure is probably better for most children and adolescents, though some prefer and others require intensive exposure to make progress against OCD. For example, some adolescents who have been battling OCD for years need to be encouraged to consider choosing higher level exposure tasks early on so that their motivation for treatment can be stimulated by seeing improvement more quickly.

Therapist versus Patient Control

The whole idea of behavior therapy often brings to mind a strong-willed therapist telling the patient what to do. Since most children already know that OCD is senseless, this usually sounds to the child like “just stop that bad habit and you’ll be fine.” Additionally, because children typically don’t tolerate anxiety as well as adults, having the therapist choose E/RP targets presents a greater risk of inadvertently turning graded exposure into flooding, which reduces compliance with treatment. It is crucial that the treatment not appear as punishment to the child. We therefore recommend telling the children up front that we won’t ask them to do anything that they’re not ready for, and that the choice of E/RP targets is theirs to make. We simply insist on progress, not on a set rate of progress.

To facilitate the choice of E/RP targets, we use the concept of the “transition or work zone.” Borrowing from Michael White again, we first look for situations in which the child is successful in resisting OCD some of the time. For example, the therapist might ask, “Give me an example of a time in the last week when you didn’t let OCD boss you around.” Using these exceptions to the rule that OCD always wins, the patient then clearly spells out a region on the stimulus hierarchy in which he or she wins sometimes and loses sometimes. This region is then labeled the transition or work zone, because (1) it defines the transition between territory controlled by the child and territory controlled by OCD, and (2) it is where the child will work to boss back OCD by selecting E/RP tasks. The concept is simple: It is more likely that the child will be successful at E/RP if she chooses to try to become 100% successful at an E/RP task at which she is already partially successful than if the therapist chooses E/RP tasks on a hit or miss basis.

Therapists may find that the term “transition zone,” a cartographic metaphor used to show the boundary between OCD and the child’s life space graphically, is more effective in explaining these concepts to some children (see Handout 2, Appendix I). For children who need a more concrete and direct approach, an alternative term—the work zone—may better increase compliance with treatment. The transition zone concept helps with selection of E/RP targets by defining a “win some, lose some” region that can be converted to “win all the time” with the implementation of E/RP. After E/RP targets are selected, the therapist can present the idea of doing E/RP tasks chosen from the transition/work zone as analogous to other work the child does on a regular basis, such as chores or homework. As with other chores, E/RP tasks chosen from the work zone require commitment and effort on the part of the child, and may to some extent get in the way of other, often more pleasant, activities. In this regard, the work zone approach communicates an expectation that the child must do the work to get better—just as he must practice the guitar to become proficient as a guitarist—and also reinforces the idea that the therapist as coach is responsible for the structure of the treatment while the initiative for change is left to the child. For some children who are reluctant to participate fully in E/RP because it is a boring chore, rather than out of avoidance, increasing the density of reinforcement (as in behavioral contracting) may be very helpful in improving commitment to treatment. For such children, the work zone concept is often more beneficial than relying on intrinsic motivation to be rid of OCD as embodied in the concept of the transition zone. For most, if not all, children, both concepts are often helpful at different times in treatment. For example, the transition zone concept works well at the start when the youngster is worried about E/RP and needs the therapist to maximize the predictability and controllability of the treatment; later, when the child is slowly moving up the upper part of the stimulus hierarchy, the work zone concept may be a better metaphor since treatment at this point realistically feels like hard work. Finally, these two concepts are often helpful in communicating to parents the difference between can’t (some things lie outside the transition zone) and won’t (the child just didn’t commit to doing the homework). Such clarification makes it easier for parents to know how much to comfort and how much to push the child with respect to compliance with E/RP.

Therapist-Assisted E/RP versus OCD Homework

OCD typically involves many triggers that are located at some distance from the therapist’s office. Going to a patient’s home or work situation can be very helpful, especially in intensive treatment protocols in which the therapist assumes more initiative in forcing E/RP (Foa & Wilson, 1991); however, this usually isn’t very practical with young patients. Since we use a graded office-based E/RP model, we rehearse in vivo homework using office-based imaginal exposure, and where possible, office-based E/RP, recruiting parents and other sympathetic individuals to provide assistance at home. Occasionally, when moving to a more intensive model because of difficult-to-man-age OCD, we go outside the office setting to provide in vivo thera-pist-assisted E/RP.

Developmental Considerations

It goes without saying that it is crucial to adjust the treatment so that it is appropriate to each patient’s level of cognitive functioning, social maturity, and capacity for sustained attention. As noted in Chapter 1, developmental considerations may interact with the diagnosis of OCD: bedtime rituals, eating or dressing rituals, and making collections of objects are common in children at different ages. Younger patients require more redirection and activities; adolescents are more sensitive to the effects of OCD on peer interactions, which in turn requires more discussion. Cognitive interventions, especially, need to be adjusted to the developmental level of the patient. For example, adolescents are typically less likely than younger children to appreciate giving OCD a “nasty nickname.” Developmental themes involving separation (becoming your own boss) and individuation (becoming your own person) may affect your ability to implement treatment. For example, children who are grappling with separation–individuation themes may find that OCD is tangled up in “boss battles,” which are inherently developmental in nature, and may consequently have some difficulty engaging in CBT. Such difficulties may be more common in the early elementary years and in early adolescence. In contrast, children in middle childhood, who are in what Erik Erikson labeled the industry versus inferiority phase, may do better with E/RP; for these children, the effort involved in E/RP itself is rewarding not only because they are beating OCD but also because it contributes to their sense of industry and, therefore, the resulting anxiety cost is “worth it.” In either case, helping the child and parents differentiate what is developmental and what is related to OCD, and how the two interact, will help move the therapist, patient, and family toward a treatment plan they can all agree on.

Graded Family Involvement

Each family is different, so that treatment must be individualized with respect to the extent of family involvement. As discussed in Chapter 19, which addresses working with families, we grade family involvement as a function of the extent to which (1) family members are tangled up by OCD or (2) family problems interfere with the treatment of OCD. Too little family involvement may reduce the effectiveness of CBT; too much involvement and therapy may not only stall, but may also (appropriately) make the family angry. In all cases, we provide family members with extensive information about OCD and its treatment and help them to ally with the affected child in the struggle with OCD. To get treatment started on the best possible footing, during the first treatment session, we instruct parents in two specific interventions, “stop giving advice” and differential reinforcement of other behavior (DRO), which are also provided as homework for the first treatment session.

Stylistic Considerations

Many therapists are accustomed to empathic nondirective listening and, especially, to play therapy techniques. While good listening skills and creative play are important to CBT, play therapy per se works poorly for the cognitive-behavioral psychotherapist who needs to actively structure treatment interventions. For example, cognitive-be-havioral therapists usually ask question after question designed to elicit details about how OCD oppresses the patient and how the patient successfully resists OCD (e.g., “Can you be more specific?”; “Tell me more about that.”; “Can you give me an example of what we’re talking about from the last week or so?”) Other stylistic considerations, such as greater self-disclosure, modeling risk taking, and extensive use of humor, are also important to successful CBT.

SUMMARY OF THE TREATMENT PROTOCOL

Table 3.2 summarizes the treatment protocol. It is assumed that the child has already completed a thorough evaluation. Treatment takes place in four steps usually distributed over 12 to 20 sessions. Each session includes a statement of goals, a careful review of the preceding week, introduction of new information, therapist-assisted “nuts and bolts” practice, homework for the coming week, and monitoring procedures. Information sheets describing the goals and homework for that week are given at the end of each session. Step One focuses on psychoeducation during two sessions in the first week. Step Two, cognitive training (CT) begins in the first week and continues in the second, while Step Three, mapping OCD, is completed during two sessions in the second week. These first three steps form the basis for Step Four, which initiates intensive graded E/RP over weeks 3–20, though many children require far fewer sessions.

In writing this manual, we have generally used the word “child” to indicate a child or adolescent. However, where special age-related issues arise, we specify younger children or adolescents. It has been our goal to use clear, nontechnical language throughout the manual so that it would be accessible to therapists from a variety of backgrounds. We encourage those using this program to broaden their knowledge of the disorder by reading many other books on OCD treatment. We have provided tips and clinical pearls in every chapter. Although these are generally included in the description of the phase of treatment where they seem most likely to be useful, such tips might be helpful at any point in treatment. It is there-fore important that therapists carefully read the book as a whole before starting treatment.

TABLE 3.2. CBT Treatment Protocol

Visit number	Goals
Session 1	Psychoeducation
Session 2	Cognitive training (CT)
Session 3	CT/mapping OCD
Session 4	Further mapping
Weeks 3–18	Exposure and response
	prevention (E/RP)
Weeks 18–19	Relapse prevention
Sessions 1, 7, and 12	Parent sessions

Step One: Psychoeducation

Step One places OCD firmly within a neurobehavioral model by linking OCD with a specific set of behavioral treatments and a desired outcome—symptom reduction. To cement the neurobehavioral framework, the therapist makes use of analogies to medical illnesses such as asthma or diabetes. Metaphors for obsessions are also introduced, with ideas such as brain hiccups or problems with the volume control knob used with younger children.

The analogy to medical illness is not as far-fetched as it might at first seem. Since OCD has its roots in disordered information processing in the brain, changes in symptoms brought about by CBT ought to ref lect changes in brain function, which is just what Lew Baxter and Jeff Schwartz discovered when they looked at images of the brain at work in OCD patients before and after drug or behavior therapy. In those patients who responded to treatment, the PET images returned to normal in patients treated with drugs and in patients treated with CBT (Schwartz, 1996; Schwartz, Stoessel, Baxter, Martin, & Phelps, 1996). Looked at in this way, patients with OCD can be approached in the same way as patients with dia-betes—only the target organ, and thus the symptom picture, differs. The treatment of each disorder involves the use of medications (e.g., insulin in diabetes, a serotonin reuptake inhibitor in OCD). In both disorders, psychosocial interventions are used to change the somatic substrate toward more normal function (e.g. diet and exercise in diabetes; CBT in OCD). Finally, not everyone gets completely well, so some interventions need to target coping with residual symptoms (e.g., diabetic foot care in diabetes; CBT, support groups, and family psychotherapy in OCD)

In addition to an extensive discussion of OCD as a medical illness, Step One also presents the risks and benefits of behavioral treatment for OCD and reviews specific details of the treatment protocol. Step One also begins the process of externalizing OCD, with younger children giving OCD a nasty nickname. By always using a disparaging name to refer to OCD, the therapist “externalizes” OCD (White, 1986) so that OCD becomes a discrete “enemy” and not a “bad habit” that may have been associated with previous punishment experiences. Adolescents frequently find this procedure silly, and prefer to refer to OCD by its medical appellation, but the principle of externalizing the disorder remains the same. Adolescents and parents ordinarily appreciate a more detailed discussion of OCD as a neurobehavioral disorder. Approaching OCD in this way allows the family and the therapist to ally with the child in order to “boss back” OCD, and thereby provides a narrative scaffolding on which to hang family interventions.

Step Two: Cognitive Training

Step Two introduces CT, defined as training in cognitive tactics for resisting OCD (as distinct from response prevention for mental rituals). Goals of CT include increasing a sense of personal efficacy, predictability, controllability, and self-attributed likelihood of a positive outcome for E/RP tasks. Targets for CT include reinforcing accurate information regarding OCD and its treatment, cognitive resistance (“bossing back OCD”), and self-administered positive reinforcement and encouragement. To increase the patient’s sense of predictability and controllability, we explicitly frame E/RP as the strategy and the therapist and parents (and sometimes teacher or friends) as the allies in the child’s “battle” against OCD. Constructive self-talk (“bossing back OCD”) and the use of positive coping strategies provide the child with a cognitive “tool kit” to use during exposure and response prevention tasks, which in turn facilitates E/RP compliance.

Step Three: Mapping OCD

Step Three maps the child’s experience with OCD, including specific obsessions, compulsions, triggers, avoidance behaviors, and consequences. In behavioral terms, this process generate a “stimulus hierarchy” within a narrative context. We use cartographic metaphors, shown in Handout 2 (Appendix I), to illustrate where the child is free from OCD, where OCD and the child each “win” some of the time, and where the child feels helpless against OCD. We call the central region, where the child already has some success in resisting OCD, the transition zone. Continuing the map metaphor, “standing” with the child on territory free from OCD allows us to strengthen the twin beliefs that we are, first, on his or her side in the struggle against OCD, and second, interested in him or her as a person who wants desperately to write OCD out of the story. In one of the clinical pearls that drives the treatment forward, the therapist teaches the child to recognize and use the transition zone, thereby providing a reliable guide to graded exposure throughout the treatment program. In practice, the transition zone is usually defined by the lower end of the stimulus hierarchy. As mentioned earlier, the transition zone can also be called the work zone.

Steps Two and Three include easy trial E/RP tasks to gauge the pa-tient’s tolerance of anxiety, level of understanding, and willingness or ability to comply with treatment. At the same time, these tasks instill the idea that it is possible to successfully resist and ultimately “win” against OCD. Trial E/RP tasks also indicate whether the transition zone has been accurately located, thereby avoiding disruptive “surprises” due to mistargeted goals for exposure or response prevention.

Step Four: Graded Exposure and Response Prevention

Step Four fully implements the core of CBT for anxiety disorders, namely, graded E/RP, including therapist-assisted imaginal and in vivo E/RP practice linked to weekly homework assignments. “Exposure” occurs when children expose themselves to the feared object, action, or thought. “Response prevention” is the process of blocking rituals and/or minimizing avoidance behaviors. Take, for example, the child with a contamination fear about touching door knobs. In this case, since door knobs trigger the obsession, the exposure task would require the child to touch the “contaminated” door knob until his or her anxiety disappears. Response prevention takes place when the child refuses to perform the usual anxiety-driven compulsion, such as washing hands or using a tissue to grasp the door knob.

As in a contest, OCD is framed as the adversary, and all parties remain intransigent against OCD. This attitude explicitly requires that the child use his allies (the therapist and parents or friends) and new strategies (CT and E/RP) to resist OCD, thereby preventing the therapy from becoming an excuse to avoid exposure. However, since only the child can do the actual combat (the E/RP), he or she necessarily remains in charge of choosing targets from the transition or work zone. We update the transi-tion/work zone at the beginning of each session as the child becomes more competent and successful at resisting OCD.

The Role of Parents

Beginning with Step One, which emphasizes psychoeducation, parents are an important part of the treatment process. Parents are explicitly included in Sessions 1, 7, 12, and 19. At the end of Step One, parents receive an information booklet (“Tips for Parents,” included in Appendix III) that includes tips for handling OCD. Parents check in with the therapist at the beginning and/or end of each session and we invite parents to comment on how the child is progressing in the struggle against OCD. Parent Sessions 7 and 12 focus on incorporating targets for parental response prevention or extinction, with the child again selecting targets from the transition/work zone. Session 19 focuses on generalization training and relapse prevention.

Homework assignments are presented each week with individualized clues to help the child successfully “boss back” OCD. We use positive reinforcers liberally (e.g., within-session praise and small goodies, such as pencils or gum, and between-session larger rewards, such as a trip for pizza with friends). In order to facilitate positive reinforcement and extinguish punishment by adults and peers, we also make a special effort to help youngsters tell other people (such as friends, teachers, or grandparents) how they have successfully reduced OCD’s inf luence over their lives.

Treatment ends with a graduation ceremony, followed by a booster session 6 weeks later.

LOGISTICAL CONSIDERATIONS

Frequency and Number of Sessions

Questions about the frequency and number of sessions are often uppermost in the minds of children and parents. The first four sessions, which mainly involve teaching and information gathering, can be scheduled twice weekly, and it is best to schedule these initial sessions no more than a week apart. In addition to building rapport and enlisting the child’s cooperation in the treatment process, these first few sessions lay the groundwork for teaching the child to think differently about OCD. It is also important to explain the treatment process early on to both children and adolescents, with particular emphasis on the centrality of exposure and response prevention. Beginning with Session 5, sessions can be scheduled at weekly or, if necessary, biweekly intervals. If biweekly sessions are necessary, we recommend using phone calls between sessions to adjust E/RP procedures.

Location of Sessions

Where should CBT sessions be held? The therapist need not be bound to the office, although often that is the case out of necessity. When the bulk of the session involves E/RP practice, field trips to places that will trigger OCD are especially valuable. The therapist should also develop creative ways to practice E/RP in the office (e.g., bringing in household items, such as a chemical cleanser, to serve as a trigger for E/RP practice).

Length of Sessions

How long should sessions last and how should they be organized? The usual format of sessions is shown in Table 3.3. Each session in our program lasts approximately 50 to 60 minutes. Before the session begins, parents are given a handout of parent tips for the week and encouraged to read these while the child is in with the therapist and jot down any questions they may want to ask during the 10-minute parent check-in at the end of the session. This procedure can be modified for adolescents who come alone, by giving parents tips for Sessions 1–4 during the first session.

The first 10 minutes of each session are spent checking in with the child and reviewing the previous week’s homework. If the child was unable to complete the homework, this time is spent identifying what obstacles interfered with its completion.

The next 20 minutes are spent presenting the goals for the current session followed by E/RP practice. As treatment progresses, 30–40 minutes of each session may be spent in therapist-assisted exposure tasks.

Before assigning homework, a few minutes are spent obtaining ratings on the NIMH Global OC Scale and the Clinical Global Impairment and Improvement (CGI) Scales (see Appendix II). This evaluation usually goes very quickly once the child learns the rating scales. We usually obtain ratings on the YBOCS at baseline, every 3–4 weeks during treatment, and at the end of treatment. We usually graph the results of these assessments, since watching the scores come down can be one of the most rewarding parts of the treatment sessions.

The final 10 minutes are spent helping the child choose the week’s homework task and reviewing strategies to increase homework success.

A brief check-in with the parent is done at the end of the session to answer any immediate questions or concerns.

As a reward for participating in the hard work of E/RP, time at the end of the session may also be allocated to a social reward (e.g., playing a game or talking about something besides OCD).

TABLE 3.3. Structure of Treatment Sessions

Session goals	Time
Check in with child and parents	5 minutes
Review homework	5 minutes
Teaching/learning tasks for week	20 minutes
Discuss and agree on homework	10 minutes
Parent review of session and homework	10 minutes

Using the Telephone

Every child in our clinic is given our home and work telephone numbers. Some of our patients also communicate with us via email. Midweek phone calls are particularly valuable because they allow the therapist to check on how E/RP practice is going and to troubleshoot problems (e.g., poor compliance; mistargeted E/RP) that come up between sessions. For example, an E/RP task that is too difficult often causes the child to bail out of the exposure and do the compulsion anyway; this in turn reinforces OCD. Delaying compulsions is helpful only if the compulsion never takes place. If the exposure task is too difficult, or too easy, a new target with a greater chance of success can be chosen over the telephone. At the beginning of treatment, we schedule telephone follow-up; as treatment progresses, the children and parents know that they can call whenever necessary.

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